After 1 year into my first private practice job I was invited to give a morning conference at my fellowship program to discuss practice building. This was around the time where I was becoming pretty upset with what I felt was a meager existence in the hospital. I sort of became the curious court jester for academic folks in the region. I was and to this day remain insanely passionate about how IRs should develop clinical practices and leave the hospital. These academic types wondered if their future fellows will end up as insanely rebellious as me. Perhaps they had room on the schedule and couldn’t get anyone else to talk. So there I was, giving conference. The talk was fine and I think was well received, but what I remember most about that day was spending a few minutes chatting with faculty afterwards. One of my mentors from fellowship remarked how exhausting it must be to build a clinically oriented IR practice with very little support. This IR is a brilliant guy who had a passion for one specific type of procedure. I could tell he was getting kind of burnt out with the hospital setting much like I was. He made an interesting prediction, which in hindsight makes a lot of sense to me. You know, I think one day there will be a split in our field where there will be a hospital pathway and there will be an outpatient pathway.
Being in the hospital is the standard for interventional radiology because this is where most radiologists are located. As more of us exit the radiology umbrella, we will certainly see more outpatient IR practices. But getting back to the hospital for a second, it wasn’t until my recent experience as a locums physician where I really began to understand that most of us are being trained to be IR Hospitalists.
What are IR Hospitalists? Well, it’s a made up term that refers to my perception of most community hospital-based IR work which constitutes a high volume of low-value procedures interspersed with relatively infrequent moments of excitement where you have to dig deep to do meaningful things like save lives at terrible hours of the night. We are often reassured by our diagnostic colleagues that we are the “face of the practice” and the “anchor for our imaging contracts.” A truly harmonious relationship they say. Yay team.
Do you enjoy collecting trash? Because if you are a hospital based interventional radiologist, you may feel like a very highly skilled, highly compensated trash collector.
And while there is nothing wrong with sanitary engineering, I think many interventional radiologists, particularly those who are hospital-based in community settings, understand relatively quickly that the job they signed up for is not nearly as glamorous as what they thought it would be based on their academic training experience.
To those trainees or medical students reading this blog, I’m really sorry to burst your bubble, but real life practice is not like what you’ve been told, unless you have really insightful mentors or trained at a community program. There is a lot of garbage collection involved in community hospital-based interventional radiology where 90%+ of you will be practicing.
What do I mean by trash collection? I am referring to doing image-guided procedures which were once not under the purview of the radiology department which have quickly become commoditized and outsourced to your friendly neighborhood IR Hospitalist. Things like:
-central lines
-paracentesis
-thoracentesis
-lumbar punctures
-joint injections
-feeding tube placement
Even in academic practices, for every one advanced case which you perform, you will do at least 4 to 5 trash cases. And please, hear me out when I use the term “trash case.” Of course these are human beings who we need to help, so we are professional in our interactions and we help them. They the patients are obviously not “trash,” but the entire situation is rather very unpleasant and can feel like a bucket of diarrhea is being poured over your head. We need to acknowledge that our 6-7 years of post-graduate training are being vastly underutilized to do commoditized cases to service the needs of other medical professionals who happened to have magically forgotten how to do basic bedside procedures which don’t require the mobilization of a team of 3-4 individuals and the use of multi-million dollar equipment. It’s hard not to be cynical. It’s hard not to feel like a caged animal, full of so much potential, but force fed into a tremendously unsatisfying existence. This issue is further compounded by the expectation that we be available at any given moment to review potential cases and perform the cases despite their clinical utility in an effort to expedite discharge, appease the wishes of families, referring physicians and hospital administrators.
It’s very easy to get frustrated dealing with the needs of the hospital, even with seemingly frequent and somewhat commoditized cases that actually require expertise in image guided procedures to execute. I’m talking about things like abscess drains, nephrostomy tubes, cholecystostomy tubes, biopsies, tunneled or implanable central venous access, bleeders of all varieties and more. Biopsies in particular drive me absolutely crazy. Yes, tissue diagnosis is of utmost importance for our oncology colleagues. It is still amazing though how the demand for biopsies alone can simply overwhelm a typical hospital-based IR department to the point that there may be little time left in your typical schedule to do other procedures, let alone have a clinic or do any of the good stuff I preach about. Anyone practicing in a center with an oncologist or a pulmonologist with a suspiciously long wait time for transbronchial procedures knows exactly what I am talking about.
It’s also funny how there are no other specialties really competing with interventional radiologists for the above image-guided interventions. Is it because they think we are so skilled and are the ones best suited to do them? If that were the case, what about procedures like venous thromboembolism interventions, peripheral arterial disease interventions and endovascular aortic interventions?
One of my IR colleagues in my hospital locums position gave me some unsolicited life advice the other day. He said the answer is always money, but what’s the question?
It’s funny, because I feel like I could have given him the same advice. Anyway, for financial reasons alone, hospital-based interventional radiologists are more or less pigeon-holed into taking on a seemingly endless stream of commoditized cases which are frankly a slap in the face to our very unique skill set with expertise in both diagnostic imaging and percutaneous image-guided interventions across a variety of organ systems and pathologies.
In theory, when you combine the historically versatile IR/DR skill set with actual clinical competence, an IR can be a true hospital MVP. I think this theoretical construct is what really draws medical students to pursue interventional radiology residency and makes for great material when trying to sell students on our specialty. IR is cutting edge. Innovation is key in our specialty. We have the ability to do some really cool stuff. We can cure cancer, spare women from terrible hysterectomies, get old dudes peeing like champs again, literally save lives by addressing vertebral compression fractures, stop bleeding from nearly every orifice imaginable through a pinhole in the skin, extract clot out of a leg vein or pulmonary artery and so much more. Just look at that list which is expanding each year! Sometimes when I do a really sweet case I have to literally pinch myself to get back to reality. Either that or the next garbage page does it for me. I probably spent the good portion of the first two years in hospital practice living to do the next “big case,” which would somehow ease the burden of Q3 call and the sad reality I had very little to no control of my time. That adrenaline rush subsides after some point and you either reach some homeostasis you’re happy with or you create a blog to air your grievances.
That reality of hospital based IR is a pure kick in the rear, unfortunately. And that is what most medical students don’t realize. I personally think IR is one of the fields that is most susceptible to physician burnout and professional dissatisfaction. The IR of the future is going to feel significant moral injury placed into traditional hospital workplace settings.
In my mind, the hospital is a terrible place to primarily practice interventional radiology. The hospital inherently forces you into a technician role. Changing cultures and attitudes in this setting is a process that can literally take years to decades. All the while you are dealing with an economic structure which makes change very difficult. What do I mean by this? Well, all that trash you’re going to collect in a hospital actually has very little assigned wRVUs. This is exactly why no one will fight you for these cases. All those “cool cases” that other specialties have “stolen,” like peripheral work? Crazy high wRVUs for those. So while we trained our competition, and failed to actually take care of patients to justify us “keeping those cases in IR,” we have promoted practice environments where we are simply at the mercy of the hospital to keep us busy and by diagnostic radiology subsidization to justify our relatively high salaries. And in some settings with many subspecialty services, you can be quite busy with interesting work falling in your lap all the time. Again, these are the “good groups.” Of course you still have no control over your life. But unless you’re in one of those settings (academics or academic like settings…i.e generally large hospitals in big cities or average sized hospitals in rural/semi-rural locations lacking competing vascular subspecialty services), chances are you’re going to be inundated with crap all day. Crap that you will collect, at very inconvenient times because that is what is expected of you. Crap like the following:
-gastrostomy tube falls out and patient goes to the ED at 2 AM. Page IR.
-all star medical intern or APP who wants to dispo like a champ decides to page you at 7 pm to request a tunneled dialysis catheter…for tomorrow.
-being inundated with biopsy requests for urgent review while being deep into your one scheduled embolization for the week.
-urologist feels it is safer for you to do a percutaneous nephrostomy at 9 pm on a Saturday, but is otherwise ok with placing retrograde ureteral stents during daytime hours for the same clinical scenario.
-medicine team needs a thoracentesis right now because the patient with a decade old pleural effusion is having trouble breathing tonight.
-cardiothoracic surgery needs a STAT chest tube POD 2 after CABG/AVR because they pulled theirs prematurely and now there’s a huge pneumothorax.
-ICU patient needs to start dialysis urgently, but is requesting image guidance for a non-tunneled dialysis catheter placement.
-Friday 5 pm declot.
There you have it. Those are all examples from a single week of locums work here in a hospital where the IRs practice 100% in their subspecialty, have a clinical presence and do exceptional work overall. Now can you imagine this same job with diagnostic radiology requirements and no clinic time?
Why on earth would anyone want that existence? Is it the median salary of 550k and 10-12 weeks off each year? It sure is a nice shovel to dig yourself out of a hefty six figure educational debt burden in a short period of time. Personally, I suspect this is the primary reason. Is it the fact that they can “utilize their entire skillset” as you read studies just hoping to catch a potential case off the list? Is it because IRs seem like cool people without the typical surgeon attitude? Is it the perception that IR is like surgery without the surgical lifestyle? My 60 hour work-week and near constant existential crisis would beg to differ.
Honestly, I really don’t get the appeal at all unless you honestly enjoy being an IR Hospitalist. This existence entails the mere possibility of interesting work which you may find satisfying at the cost of significant time and control of both our professional and personal lives. All the while existing in a site of service which is abusive to its patients and physicians with a very obvious profit motive. In fact, had I known that this is the reality for the vast majority of IRs, I’d find something else better to do with my time and hard earned education. Perhaps something that allows for a more focused clinical existence and the ability to still do image-guided procedures yet have some control over how I’d like to practice.
Yes I am being negative and perhaps somewhat provocative to get your attention, but I truly believe I’m one of the few who is willing to write this publicly and non-annonymously for your consumption. The economics of the situation warrants this reality which I have described. If you talk with many hospital-based IRs, you’ll hear variations of the same theme, oftentimes with coded language or subtleties to maintain some semblance of decorum as to not frighten the children. And frankly, many IRs are just too naive to realize that this is their life. Hate saying that, but it amazes me when many don’t understand the financial structure that shapes their professional existence.
Sure, there are ways to improve your hospital based life. You can be in a very large group which is highly subspecialized with appropriately trained APPs to allow you to practice “high-end IR.” You can pursue academics where you have an army of poorly compensated trainees to handle the things you don’t want to deal with. You can also declare yourself a full time locums doctor and clearly define what it is you are willing and not willing to do to make a living and hope the insane money you make which allows for potentially more time off can help you avoid burnout.
Despite all of this, the fact remains that hospital-based interventional radiology isn’t all that it is talked up to be. Reality can be harsh and I think it’s important that every aspiring IR realize this.
I strongly believe our future growth will not be in the hospital setting. Hospitals are money hungry, inefficient and frankly dangerous places which do not keep in line with the innovative, cost efficient and minimally invasive nature of our specialty. But they are still necessary.
Every hospital needs at minimum two IR Hospitalists. Real MVPs who can do it all. Everything from a feeding tube placement to a 3 AM TIPS. Despite the trash collection, there is no doubt that a good hospitalist IR is literally worth millions. We’ve all worked with those senior IRs who can do it all and somehow managed to keep their sanity for 30 years. God bless their souls.
And look, there are all sorts of interesting thoughts out there to justify our worth to hospital administrators. Fun things like looking at money saved from reduced length-of-stays and demonstrating the value of clinics through evaluation and management coding in addition to increased procedural revenue in settings historically labeled as cost-centers and things like that. It’s sad to think that there are academic IRs who have literally made their careers discussing these tactics, forming committees and those committees forming sub-committees etc. With my sincere apologies for their hard work, I think these endeavors are largely futile because no hospital administrator really cares. Unless that economic benefit is tangible in readily identifiable reimbursement revenue which can compete or exceed the traditional fat cats in the hospitals (orthopedic surgeons, oncologists and cardiologists), they’ll “circle back” to you never.
So what should we do if we don’t enjoy hospital based IR? Instead of negotiating to change our circumstances within the hospital-setting with people who refuse to understand you, change the game and use our inherent economic strengths in the office setting to create the leverage necessary to create real IR practices rooted in actual clinical medicine. Divorce professionally from diagnostic radiology not because we don’t value imaging or our relationships with our friends and colleagues, but for the pure fact that our economic value is not inherently aligned in the hospital setting where theirs is maximized. It’s a pure business decision. In American medicine, if you don’t play this game, you’ll get crushed. Let’s be our own anchor, not one for diagnostic radiologists. Leave the hospital with the primary focus being a strong outpatient economic engine which fuels a robust IR practice. Let the diagnostic radiologists focus on creating value through ACR Imaging 3 point million or whatever iteration they’re on when you know you don’t need that to justify your value because IR is patient facing 24/7.
Here are the ridiculous hoops that have to be jumped through to get to this reality of independent IR practice:
- Actually get into an IR training pathway which is now surprisingly just as competitive as dermatology and plastic surgery.
- Get really good training, including in peripheral arterial disease. Good luck if you are like 90% of us who don’t end up in one of the 5 or so programs offering this training in IR.
- Get really good at diagnostic imaging because you’re going to need it to make money while you build your IR practice. Good luck getting good in 36 months if you choose to partake in the new IR residency pathway.
- Learn to become a competent IR early in your career. It requires mentorship and 3-5 years of hardwork despite what you may think. That mentorship isn’t always readily available and those first few years require forced consumption of humble pie.
- Build a clinical practice and regional reputation. Not easy to do in most hospital settings.
- Break away from the hospital and create an outpatient based practice or join an existing one. Magically navigate non-competes to make this step happen. Will likely require significant legal fees.
- Maintain or get new hospital privileges and deal with pseudoexclusive contracts. Again, good luck.
- Invest significant capital for the creation of an outpatient center ($300,000 minimum for a new build OBL, millions for an ASC). Contend with state certificate of need laws as necessary. Again, more money burned.
- Work hard to build a referral base if you don’t have the luxury of one already which will follow you from the hospital to the OBL/ASC, which you probably won’t.
- Hire good non-physician partners who can assist with things like practice management, credentialing and revenue cycle management because it is nearly impossible to take on these tasks and practice good IR. Don’t get swindled by those wanting sizable equity.
- Pray that reimbursements don’t continue to get slashed.
- Keep forcing yourself into thinking that what you are doing is good when many of your colleagues think you are a “rogue” or “egotistical.”
How many people will accomplish this? Very few. I’d contend that perhaps 5% of future IRs, and that in itself would be an incredible accomplishment for our field.
Most will decide the headaches of this route aren’t worth it. First and foremost, while it’s not popular given the wave of “clinical IR’ hype (which I believe in), I know for a fact many trainees are interested in a standard IR/DR existence even though they may say otherwise on the interview trail. For the growing proportion, though still likely a minority, who inherently don’t enjoy hospital IR work, golden handcuffs of hospital life may seem ok as they grow into their incomes and inertia sets in. They’ll get to their 40s, focus on passions outside of medicine and go on their merry way and be happy to mentor the next generation of passionate Line Monkeys who are willing to absorb their call for the chance to do some cool cases. The IR hospitalist life will remain alive and well for the foreseeable future. Most of you will end up living this existence.
Others will decide that they do want the outpatient 100% IR life, but they don’t want to deal with the headaches of running a business or risking hard earned capital. They’ll likely be undervalued employed labor for existing OBL sharks or corporate entities and never realize their true economic and clinical potential. I know there are many in the OBL space just waiting to take advantage of all the cheap misinformed labor about to flood the market in the next 10 years.
The ones left over will feel empty inside, frustrated/pissed-off and hungry for more. Are you willing to jump through the requisite hoops to practice independently?
Well, despite the sobering and cynical tone of this post, I sincerely hope that you do go down this windy road. It’s quite scenic and there is always beauty in the struggle. Despite our challenges, we are a field in its infancy. We need the best minds to shape our future direction. Physicians need to become owners and take back medicine from insurance companies, administrators and a good number of non-physicians who always have wonderful new ways to “add-value” to your existence. There is no better way to do this than to create your own practice. I have found what makes me passionate and it is helping us push ourselves towards the goal of having more independent IR practices, even as I navigate the hoop jumping in real time and document everything right here, for your entertainment.
If you are a IR hospitalist and enjoy the work, I applaud you and thank you for your contributions. You deserve to be celebrated, even though I know you’re probably not. Cheers to you.
If you are a medical student who is now afraid of doing IR, do yourself a huge favor and spend a day or two with an IR in community hospital-based practice and form your own opinions and take everything you hear with a healthy dose of skepticism, including those medical student hype symposia or these blog posts. I would assume you are not going to end up working in an OBL and I certainly would not go into IR with this primary goal unless you are ok with the opportunity cost which is a better defined future in a competing organ-based procedural field.
If you found this post good, bad or just ugly, please comment below.
Great post. Lots of truths. Well balanced despite the cynicism.
Thanks for the feedback! I think the cynicism struck a nerve with some. Looks like I accomplished my task.
Based on this post it sounds like you would have rather done Interventional Cardiology or Vascular Surgery. Would you advise medical students who would like to do IR in OBL that they are better off doing cardiology or Vascular surgery?
Every field has its pros and cons. My former partner is an interventional cardiologist and my wife is a vascular surgeon in training so I know these fields better than most. What I can say is our field has been devalued, gutted and more or less destroyed while these fields have absorbed vascular work which was once predominantly done by IR. Why? Because we don’t take care of patients primarily and our pseduoexclusive contracts prevent us from becoming independent to practice as we wish. Apply for privileges to hospitals, get rejected dozens of times and then tell me what you think. Neither of these fields have these issues. I think our training is improving in IR, but for the pseudoexclusive contract reasons alone rooted in our on-paper relationship with diagnostic radiology/ABR, i unequivocally advise any medical student who only wants to do IR in the OBL to not walk, but run away from this field. So yes, I would advise them to do IC or VS instead as much as it pains me to say so. Those who disagree are those content with their hospital existence. It’s usually 1.)the 10% who are either in academics or those in “good groups” without aggressive vascular specialists competing with them for procedures, often in semi-rural/rural locations or if in major metropolitan locations because an appropriate clinical culture was instilled decades ago by IRs ahead of their time, or 2.) part-time IRs who enjoy being IR/DRs and don’t care for vascular work or building large patient panels because that defeats their reason to pursue radiology from the start.
The exception to my advise being those who are willing to chance it and are ok with a career as a hospital based IR/DR as a back-up option. Just for clarification*
I think it takes one seeing to believe the truths you have described. As a medical student or even an early to mid resident, paras, thoras, central lines, etc aren’t “trash.” It’s only after one has gained good experience in the full breadth of IR and gets an understanding of the business and financials of IR that they can understand the “trash” of IR. To be clear as you stated, the term “trash” is not meant to demean the patient. Some of the most mundane things we do are exceedingly valuable to patients and the health care system. Abscess drains and cholecystostomy tubes prevent patients from going to surgery and dealing with all that surgery entails (morbidity, mortality, cost, extended hospital stays, etc). However, the current health economic system doesn’t reflect their value and thus the value of the IR. Sadly, most medical students destined for IR, residents, new and seasoned IR won’t realize and accept their value. Thanks for your work and voice linemonkey.
Very well stated. I appreciate the comment!
Great article. The truth hurts but I know now that I am not alone to think this way.
Here I was, early in training, day dreaming about my amazing future as an IR… crushing cool cases. If 5 percent of us avoided this future it would be a success. Sheesh…
If 5% of future trainees engage in the entrepreneurial activities needed to develop new practices independent of hospitals, that would be a great benefit for our field. My recommendation is students not pursue IR if they don’t think they’ll be happy with a hospital based existence unless they’re willing to be entrepreneurial and take the risk to create their own outpatient practice.
Excellent article and it’s true for vast majority of IR’s in community hospital setting.
I think call frequency, intensity and culture of the hospital plays a big part in all this. Not possible to practice 100% IR on a RVU basis in community hospitals given the amount of “trash” cases.
There is a business case to be made to offer IR service even if it’s trash cases as it moves the patients and impacts care. Agree that as much as possible; IR should move away from hospitals.
Thanks for the comments! Agreed.
On point with the negatives of IR. It is very rewarding when you can turn around a “trash” service into “complex” service. Rebuilding relationships with competition and reestablishing lost cases or being their bailout. I think the new generation will have a tough uphill battle to reassure the hospital that we are more than the trash can.
Thanks for the comment! I can see how rewarding that could be. It’s a tall task to change a culture in an often disjointed vertically integrated hospital setting with varied financial (and other) motives. Lots of potential for future trainees. Lots of pitfalls too!
Thanks for this insightful post. This is my reality for the past 20 years and I’m so glad I’m finally making the jump to the OBL setting this year!
I’m excited for you! Thank for checking out the post!
Excellent post. Only commenting to say I cannot agree more. Would love to meet you for a drink at future IR meetings.
You going to OEIS? Either way, I’ll e-mail you. Your blog by the way, is awesome. I know life is busy, but you gotta get back to it. I loved reading your early stuff.
All excellent points. My perspective has always been each specialty has its trash, so if you can tolerate your trash, you’ve made the right choice.
I’m at a small enough hospital that I know many of the referring docs and they know me. There is a mutual respect and they try not to dump on me. If I push back for whatever reason, they’re willing to hear me out.
I think IRs are exceptionally prone to burn out and this is under appreciated within radiology. It is amplified on the private practice end (turf battles with other specialties, lack of support with practice building, conflicts with DR).
Wise words from a wise man. Thanks for checking out the post.
Great points as usual. Service line development of disease processes is paramount to long term durable success. BPH and LUTS management not PAE, Abnormal uterine bleeding/ pelvic pain not UAE and gonadal vein embolization. PAD/leg pain/ limb salvage not SFA atherectomy.
Hard to do this without adequate infrastructure of dedicated office hours to see and counsel patients , comprehensively manage diseases and follow patients in a longitudinal fashion. Hard to do this while trying to stay on top of the never-ending imaging list.
That’s right. Thanks for checking out the blog. We need to develop clinical practices. That’s how we stay out of the gutter.
Dr Monkey has addressed this elsewhere I presume but for clarification purposes to the early career folks the reason the IR hospitalists are stuck with the “trash” is because of the “Exclusive” Radiology contract. Typically, it is mostly exclusive for imaging but nonexclusive for interventional procedures. Pretty much any specialist gets to do any procedure they want (VS/IC performing PAD, neurologist/NS performing near procedures, and VS doing anything they want like trauma embolization, pulmonary thrombectomy, etc). That is why some folks call it the pseudoexclusive” contract. The only people it blocks are independent IR’s who want to get on staff; those are the ones who have a clinical practice and the ability to compete with the other specialists. So what the silly radiology contract gets the group is NO guarantee of any good cases and a contractually REQUIREMENT do all the cases that no-one else wants to do!!! Or none of the good and ALL the TRASH; of course trash doesn’t pay or else another specialty would take it.
Dr Monkey is correct in what he writes but unfortunately the SIR (or the society of hospital based IR’s in radiology groups) has done almost nothing to change this in the 30 yrs I have been practicing. Get out of the hospital! Stop wasting your training.
Great comment. I’ve been saying this to my colleagues for the last few years. Kudos to those who have “gotten out”. I’ve acquiesced and chosen to just shift my mindset. No longer expect any professional satisfaction. I’m paid well. Punch in punch out. Focus on family and golf. Cheers
You could write this blog post if you really wanted to. Wholeheartedly agree.
This article is 100% spot on. I am a Hospitalist IR (cover 3 community hospitals) and also read diagnostic. I thoroughly enjoyed reading it and completely agree with your take on the grim reality of our profession as you see it. Thank you for sharing.
It is possible to be private practice DR/IR and have cool cases, but it is geographically and temporally challenging. I have been lucky, and I don’t mind doing port days. I just wish I could convince my DRs that we could have those port days at an OBL or ASC and end up killing it financially. He hospital would lose it’s mind, of course, but chasing professional revenue is a race to the bottom. Ateast we capture a good deal of the follow up diagnostic studies at our outpatient facility. It is truly sad that what you say is mostly true. Physicians in general are not business savvy or knowledgeable about finance and administration. This trend is not unique to IR. Keep fighting the good fight and maybe the next generation just needs to decide what kind of life they want and what risk they are willing to take to get it.
Thanks so much! Agree with what you said.
Ideal world: various specialists who could all potentially treat a specific disease collaborate to decide on the best treatment for a specific patient and have the specialist with the best skillset for that treatment perform the procedure
Real world: cash rules everything around me, C.R.E.A.M get the money
speaking to my friends in various PPs, there are CT surgeons running vascular labs, vasc surgeons doing UFEs, general surgeons doing EVARs, and neuroIRs doing PAD (prob the least egregious). honestly, the best non-academic IR jobs I’ve heard of are at places that dampen or remove the C.R.E.A.M mentality (some VAs, integrated managed care like Kaiser, etc.) With our current financial landscape, it’s a tough road…
Wise words. CREAM is real.
By trash, you mean disrespectful abuse of a skillset by both referrers AND CMS. CMS because if a thora was 5 rvu, I guarantee the clinicians would find their competence in 2 weeks flat. Its an interesting place to practice, and real talk: if it was my family, id prefer IR to a bedside puncture every time.
True. But I think part of this too is our lack of interest/motivation to build clinical practices regardless of the reimbursement (though not denying it’s important). I do agree. Id want that seemingly menial procedure done by an IR.
I started in private-practice IR in 1999. Back then we did peripheral and renal angiography and interventions, cerebral angio and stroke interventions, pulmonary angio, fibroid embolization, and a much greater volume of biliary interventions. Having acquired so much experience by doing tens of thousands of such complex cases, now IR is mostly limited to venous access and dialysis interventions, nephrostomy, gallbladder drainage, and the sporadic trauma embolization. This is in the background of a large number of paras, thoras, LPs, and joint injections. It is very easy to feel as if my training and experience is not being utilized at a meaningful level. Such a shame because I have personally seen in the first part of my career how much positive impact we can have doing complex cases in IR as opposed to them being done by other specialities.
The devaluation of IR is real. What you describe is what many of my senior colleagues describe. It’s disheartening. Thanks for your comment!
I couldn’t agree more with your article. THANK YOU for writing it.
We need to abolish pseudoexclusive DR contracts that prevent our own IRs from having hospital privileges. All while allowing other services to do what they want- while also dumping trash on the IR hospitalist!
Which IR society will support making pseudoexclusive hospital contracts illegal? Or do we need a new society without Radiology in its name?
Thanks for the comments! I don’t have faith in the SIR when it comes to this issue. The leadership on the whole does not reflect reality. I know there are hardworking individuals in leadership roles with great intentions, but collectively I have my doubts. I focus my energy and attention on OEIS. I do think our formal affiliation with radiology is a big issue. I do think there needs to be a divorce on paper.
Could not agree more. I practice in a community setting and about 5 years post fellowship. The amount of “trash” procedures has just climbed exponentially with more midlevels staffing the ER, ICU and hospital floors that just dump insane amount on our department (i.e removal of tunneled and sometimes nontunnneled lines), LPs, joint aspiration, etc.). There has been a real hollowing out of experienced physicians who would have been frankly embarrassed to ask these kind of “consults” even a decade ago.
Absolutely. I’m of a similar vintage and have noticed the same trends myself.
This is a thoroughly entertaining and thought-provoking post. By your definition, I’m absolutely a garbage man. I do, however, have financial security, appreciation from my colleagues, and general career satisfaction. I only occasionally do TIPS (harvested from paras), PAD (harvested from dopplers), biliary work (harvested from intraoperative fluoro images on failed ERCPs), endoAVFs (harvested from tunneled dialysis catheters), etc… but I feel it’s worth noting that IR is unique in terms of the breadth and scope of procedural work it affords us. In the best of situations, neither IC nor VS can even approach the procedural variety we enjoy. I’ve worked in OBLs and ASCs (still occasionally cover them as a locums), which is also enjoyable and certainly more lucrative, but being a garbage man does have its upsides.
Thanks for your comments! I agree, being a garbage man isn’t the worst thing in the world. There are perks.
I am an IR with an IR/DR group with an exclusive radiology contract. Our group made a conscious decision to support IR as a clinical service. Fast forward several years we now have the busiest outpatient IR practice in the area performing the full breadth of IR cases including PAD, UFE, PAE, GAE, IO. We still put in our time as IR hospitalists, but our group is now bringing meaningful outpatient cases to the hosptial. And all of this is still under our combined IR/DR group.
Interested to hear more about your IR/DR practice and what makes it different! I’m a PGY-4 IR/DR trainee. If you’re willing, would love to connect -webreaktheglass@gmail.com
My IR/DR practice is me living out of a suitcase doing locums. There is nothing special about it, though might seem special to some! Check out my locums post. I’ll write more about this. Thanks for checking out the blog!
Can you as an IR within an IR/DR group hire a PA (100k per year) to do more “trash” procedures while you do more high end cases?
Sure. There are plenty of groups that do this. Now whether or not they do it to free you up to develop a clinical practice which will yield high end cases or to just crush a list of studies is a different question.
Sounds like you have a harmonious group which remains more the exception than the norm. Glad you found a setting to build your clinical practice.
Well, consider yourself in the lucky minority. I’m happy it’s working out.
A lot of truth to what you’re saying, but you don’t have to accept a practice in the Hospital. Join OEIS (oeisocirty.org) ands you’ll meet a lot of IR physicians and other specialists that live in the OP world. You can carve out the IR life that you want. It is challenging and not easy, but it is very rewarding doing what you love to do in a setting where you have the control.
I’m looking for an IR to join my 100% outpatient fibroid IR practice. If you or someone you know is looking for this type of opportunity, send me an email (John@ATLii.com) and a CV. Thanks and good luck. John Lipman, MD, FSIR
Great connecting with you the other day, John. If I hear of anyone I’ll let you know.
Great article Kavi. You figured things out pretty quickly! Would love to pick your brain at some point soon to hear how your OBL experience has been.
Thanks! Anytime D Tran. Hope you’re well.
Spot on man. Nice article.
Thanks!
It cannot be over emphasized, pseudo exclusive contracts are and have always been the main issue to succeeding as an IR in the hospital setting.
The outpatient setting is challenging mainly because of the undervalued reimbursements of course, and also the local referral patterns, which are notoriously fixed.
I agree regarding PECs. Thanks for your comments and checking out the post.
So much truth from one that is just one year in private practice. It took me 20 years and a midlife crisis to figure it out. I am a solo IR doing pad, veins, uae, kypho, dialysis, ports in my obl for past 10 years and have found that the diversity of my practice has a synergistic effect in getting crossover patients. Vein patients needing pad treatment who one day may need kypho. Or esrd patients needing declots and pad treatment for example. Afterall, these are your patients who will continue to look to you for medical advice after the initial consultaton. The hurdles that you listed are difficult to overcome but can be done. And for those of you who do start your obl, you will find that you have catheter skills far above the vascular surgeons and cardiologists. I agree with John Lipman that OEIS is a good resource for those interested in outpatient obl. I agree that SIR represents interests of hospital based IR mostly. If you have any questions feel free to respond.
Great comments. Thanks so much for sharing your experience and checking out the post.
There is a stark reality that is not addressed in this otherwise great article. Depending on where you practice, an OBL is a pipe dream.
Young physicians, please understand. The vast majority of health care is delivered by networks. Networks own the hospitals, and the referring practices. Networks decide where patients go. Physicians do not decide. In reality, patients do not decide. My area is entirely controlled by two competing networks. Less than 5% of providers in my half of the state are independent. That includes psychiatrists and podiatrists. Most of the independent physicians are independent for a reason. They are the stray dogs of medicine.
So if you open an OBL here, please get used to the sound of crickets. No one is going to send you a single patient. All network physicians or providers are required to refer in network. So if you open that lab, at least here, you are going to be relying on the stray dogs, to send you cases. Good luck. A six figure education debt is terrible. But a seven figure debt on an empty OBL is way worse. Especially when the only entity that will buy it from you, is the hospital you originally chose as your competition.
The exclusive contract the big group has with the local network isn’t the enemy. That contract is actually the way some IR guys, probably a lot like you, found the best way to practice. Those IR guys do take out their trash. But they also do embos and PEs and cool kid stuff.
So if you go outpatient, have a B plan. Especially if you do not live in a ‘Right to Work’ state. Once are in that OBL, you are one merger or acquisition away from not only losing all your referrers, but also being persona non grata at the only place that could employ you.
This is a very good point, but markets vary widely. I helped create an OBl. I know this reality. Everyone has to do their homework. But to not even have the choice because of pseudoexclusive contracts? That to me is unacceptable.
Agree.
However, not all exclusives are pseudo-exclusives. Some actually work quite well for hospital and IR physician.
That’s right. Exclusivity is what it is. But there cannot be double standards which happen to be more the rule than the exception when it comes to radiology services.
Well, what you summarized here represents what’s going on with the true and with the pseudo private practices where I live. I realized this on my recent job hunt. Training wise, I have been fortunate to have been exposed to and trained in pvd, nir, dialysis management, evars all within the IR department. It’s a blessing but may also be a curse because I long for those types of cases on days that are filled with “trash”. In the end, it will be my responsibility to create a clinical service line to treat pvd/limb salvage, IO, etc etc. If the practice I join can’t accept the start up costs or if it favors high volume but low end procedures then I walk and go at it alone. In the intermediate to long term though, outpatient centered is definitely where I would want to practice.
I have also been fortunate to experience the obl side during my training: shorter days, consistently higher end cases and clinic. We even take an hour lunch break! I think the job satisfaction is wayyy higher than a 100% hospital based practice. At the same time, one must pay their dues prior to such an endeavor. Most trainees won’t have the clinical street smarts or the capital to jump right into this.
You have the right mindset. Combined with your training and overall perspective I look forward to seeing you do great things!
Great article, and it definitely highlights some of my frustrations. I work primarily in a hospital, but am part of a dx/ir group that values our clinical practice and supplements it. We do mostly IR, and have clinic time. From reading peoples posts, I think it’s hard to find that type of group.
Working in the hospital can be frustrating with all the requests for minor procedures that others magically no longer know how to do (Er can’t do a Thora?????). We establish boundaries on what we’re willing to come in for on call (very important to have relationships with respect of your colleagues), but frustrations still arise and you’re stuck with it in the patient’s interests.
But that’s only part of it for our practice, and the rest is pretty rewarding.
Our hospital is relatively small, and there aren’t many “super specialized” specialists (biliary surgeons, transplant docs, advanced endo GI, trauma specialized surgeons etc) in the immediate area, so a lot of complex consults and cases do fall in our laps since the other docs know and respect us— in the hospital but also in clinic. “We don’t have anything to offer, call IR.” Even if it only results in a consult, it’s straight up clinical medicine, which is rewarding and engaging. You’rE not just a technician or proceduralist, you’re involved in the decision making.
Good luck to all the trainees out there. It’s not all black and white, so like the author said, see what’s out there and make your own decisions. Either way this article is great since it points out some of the reality you may not see until you’re out in practice.
Thanks for the kind words, sharing your experience and taking the time to check out the site!
Preach. Constant, constant fighting against all the shit everywhere. No more! I GTFO’ed and do mammo now. I’d rather have left medicine altogether but I love it!!! Like you suggested, it’s “something that allows for a more focused clinical existence and the ability to still do image-guided procedures yet have some control over how I’d like to practice.” That’s mammo, not IR (at least not in 2022). IR will be great in 20 years but Im not sacrificing my life to that cause anymore.
I think this is a fair point. Nothing moves quickly and you have to make the right move for your mental health. I’m glad you found something you enjoy doing! Thanks for checking out the post.
Would you advise medical students who are mainly interested in DR but like procedures to go into IR/DR? Overall is DR more lucrative than IR?
What do you think about Columbia’s work in the outpatient setting in NYC?
a number of DRs these days come out of training timid to do any procedures. had a good friend from residency who shied away from doing anything but reading cases in training and ended up getting fired from her first job (in a locale she wanted/”needed” to be in) due to being unable to confidently do paras, thoras, US/CT biopsies for her group. On the interview trail for residency, I recommend grilling the residents on #s of procedures they get to do and how often they have to fight with fellows for them. There are some good residency programs with few/no fellowships that tend to generate DRs who are very comfortable with a wide variety of procedures.
I think Columbia’s academic OBL model is interesting. I only know of it and do not have first hand knowledge.
If you are mainly interested in DR and like to do procedures I’d advise against IR/DR and would do a DR subspecialty that has the potential to do procedures.
DR has a more well defined path to making money than IR. IR can do just as well as DR in a traditional hospital based practice. IR can do even better if one is entrepreneurial and opens their own office. Ceiling is higher in IR, but floor is also a lot lower. Don’t do it for the money. You’ll be beyond fine financially either way.
just kissed twitter goodbye for the time being with recent events, so will be here for the juicy convo and your educational content.
Definitely feels like hospital based IR is simultaneously being the MVP and “dumping ground” because in a weird microcosm way, we are the clean up crew for the hospital based “throwaway society” . Being an IR has actually weirdly inspired me to be more curious about all the wastefulness of our society and healthcare system. Though I don’t have the answers, I have always thought the concept of risk has also shaped the convo around these procedures. Yes, they don’t pay well so why take the risk for something many residents and interns don’t get enough experience with in training?
We are forced to be very bureaucratic with our solutions because physicians are punished for taking understandable risks while celebrated for taking unnecessary risks. The “safest” thing to prevent more flak is to spread the risk and procedure components to IR because we are victims of our own success, doing things relatively easier and faster despite increased costs. I still love IR and enjoy my clinical practice. Connecting with the patients is great and providing new solutions is awesome. Like anything, over time some bright idea person (usually an admin who wants a quick fix) eventually silently takes away resources and expects you to do the same or more with less personnel, equipment, and support. Seems to be how most us humans operate, taking others for granted and gaslighting anyone who is unhappy, all in the ultimate quest of maximizing pay while minimizing effort/risk.
“Because adherence to standard operating procedures is difficult to second-guess, decision makers who expect to have their decisions scrutinized with hindsight are driven to bureaucratic solutions—and to an extreme reluctance to take risks.”
― Daniel Kahneman, Thinking, Fast and Slow
https://en.wikipedia.org/wiki/Throw-away_society#:~:text=The%20throw%2Daway%20society%20is,for%20reuse%20or%20lifetime%20use.
“Seems to be how most us humans operate, taking others for granted and gaslighting anyone who is unhappy, all in the ultimate quest of maximizing pay while minimizing effort/risk.”
I couldn’t have said this better myself. Thanks for taking the time to share your thoughts!
Wow…. so glad you’re using that big brain to do/say good things. Always admired you in residency. Cheers, Homie!
Thanks man. Hope to kick it with you soon. Preferably again in Maui, this time without the need to present an abstract!
Did you consider a path do a subspecialty such as NeuroIR or Paediatrics (perhaps not due to likely more trash in paeds!) in order to reduce the general trash that comes your way?
Hi Ronan, thanks for visiting the site! I originally wanted to do NeuroIR but decided against it because of the length of training and relatively narrow scope compared to IR. I did not consider peds IR, but I know it can be a very rewarding subspecialty. Ultimately I chose IR because of its diversity. IR is unlike any other field in radiology. I would argue radiology is simply a tool to practice IR. We are image guided surgeons. In my mind at least. The “trash collection” doesn’t have to be that way, but happens to be common simply because of how we are structured as part of radiology departments. It has nothing to do inherently with IR as a field itself. I’d say peds is basically DR with the ability to do some procedures. NeuroIR is very variable like IR, but in many settings comes with more diagnostic work depending on the volume of work etc. I’d spend time with an IR and see if it’s something you’d like to do.
Hello there, rising 4th year applying into DR with an eye on ESIR. Had a similar question as Ronan regarding pedsIR and neuroIR, and I apologize for some redundancy. But would you say peds/neuroIR docs are spared these line-monkey hospitalist IR procedures, at the expense of heavier emphasis on DR and a narrower scope of work? Do most hospital admins consider these subspecialty IR fields as discrete entity, and separately hire a more general IR group that takes on the the mundane procedures and medical consults? Appreciate your time.
Depends on where you practice.
The peds IR volume in private practice is low at most places unless you are covering a peds hospital (but many of those are affiliated w/ universities). As such, you’re going to be spending a lot of time either doing adult IR and/or DR. Not the case everywhere but in general. If you go academics you can do a much higher % of peds IR. But even in that setting you’re probably going to end up doing a significant amt of PICCs and other minor procedures.
Neuro IR in private practice is varied from the people I know. Stroke volume is there in many places but elective cases like aneurysms AVFs etc are going to be less common. As such most neuro IR trained docs I know in PP do a substantial amt of DR. Some PPs want them also doing body IR procedures.
Ultimately if you a private practice radiologist (DR or IR, sub-specialized or not), there’s a decent chance you’re going to get dumped on re: minor procedures.
Interesting read. But very biased and inaccurate. Very narrow perspective. I don’t know you but you must be a millennial. And crazy entitled. And naive. Junior people in every job in every field do the less desirable things. The senior people do the more desirable things. You are very junior and complaining a lot because you are not doing the idolized sexy things 100% of the time. High level practice takes a decade of hard work and high performance and perseverance. Do you know any junior or mid-level pediatric surgeons? Pediatric surgery training makes IR training looks like a joke. Yet, they insert many, many central lines. And many, many G-tubes. Only occasional complex cases. And they get paid less than IRs. And they don’t cry about either. Do you know any trauma surgeons? Training is way harder than IR training. They are lucky to do one real trauma surgery per week. Even the senior ones. They spend most of their time idle or cutting open abscesses. Repairing hernias. Debriding wounds. Round on SICU patients. 90% basic stuff. They don’t even get to operate a lot. Get paid less than IRs. Do you hear these surgeons crying about the less glamorous parts of their job? eblasting social media to proclaim how bad their specialty is? Discouraging students from pursuing pediatric surgery or trauma surgery? Your negativity is off the charts. How can you say anything about a good IR job if you have never had one? Maybe your exuding negativity is why you have never had a good IR job, and doing locums? Maybe you were not meant for medicine? Passion for helping people is necessary to be fulfilled. Want to be rich? You will be disappointed. You are a good writer, maybe that is your true calling. I enjoy reading your posts. Try optimism and a new perspective and then try to join a really good IR practice. You will be amazed at how good IR can be in a good practice. Be a part of a team. Embrace and help your partners. Maybe that is what you need. Or just take the plunge and start your own OBL. Once you reach happiness I hope you will post and spread the word. Sing the IR praises. What you are doing is a pestilence to IR. I wish you the best and am praying for you.
Thanks for your comments. I am praying for you as well.
I forgot: I was trying to pray for you, but all I had to go on was “Annonymous” from New York City. Can you please post your name so I can make my prayers more specific? Thanks.
“It is still amazing though how the demand for biopsies alone can simply overwhelm a typical hospital-based IR department to the point that there may be little time left in your typical schedule to do other procedures,”
And then we have interventional radiologists who think nothing of tying up pathologists’ time for hours on end, keeping them on-site to make sure the IR got adequate biopsy tissue. Hey, it’s not like pathologists have any other responsibilities. 😉